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Addressing the treatment gap for perinatal depression

Reposted blogpost by Tasneem Kathree, first published at @MHInnovation

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Making the link between food insecurity and maternal mental health

Food insecurity is an ongoing concern in Africa. According to the State of Food Security and Nutrition in the World report by FAO (Food and Agriculture Organization, 2018), the number of undernourished people has increased to nearly 821 million worldwide. Africa remains the continent with the highest prevalence of undernourishment, affecting over 250 million people.

Recent studies show that women with children make up a significant component of the households affected by food insecurity. In our Q&A we highlight this important topic and its connection to maternal mental health.

Read the full Food Security and Nutrition report here

What is food insecurity?

Food security is defined as having enough safe and nutritious food to sustain a healthy life. In contrast, food insecurity means that food is not sufficiently accessible or affordable, so households have difficulty securing adequate food.

What is maternal mental health?

Maternal Mental Health is a term that refers to the emotional state of women during and after pregnancy.

You can read more about perinatal mental health on our website

How is food insecurity linked to maternal mental health?

The relationship between food insecurity and poor maternal mental health is complex, with research showing that there are bi-directional associations between them. That means that suffering from food insecurity can have a negative impact on mental health and having mental health problems can negatively affect food security. The Perinatal Mental Health Project demonstrated these associations in a paper published in 2018.

How does food insecurity affect maternal mental health?

The negative physical health effects of poor maternal nutrition are well documented. Additionally, the emotional strain associated inadequate basic household resources, and how these resources are allocated substantially increases the overall household stress. Food insecurity can have persistent effects on the mental health of household members, especially those responsible for child care.

How can mental health problems during or after pregnancy affect food security?

In low-and-middle-income countries, maternal depression can is associated with an increased prevalence of food insecurity in the household by 50 to 80%. Mental health problems also impact the way food for the household is sourced. Mothers with depression or anxiety may find it more challenging to generate income, make contingency plans and draw on social networks for support. They are more likely to be in relationships characterised by abuse and control.

Breaking the cycle of food insecurity and poor maternal mental health!

Even though the link between the two highlighted issues is being explored worldwide, there is little evidence for interventions that successfully break this cycle.

Currently, many interventions target one or the other issue. While food banks and support grants are aimed at improving the nutrition of mothers and consequently alleviates household food insecurity – they do not address the mental health implications of food insecurity on households. Similarly, maternal mental health services do not typically poverty relief or similar interventions, which could reduce the negative impact food insecurity has on households.

Combined interventions need to be developed and tested for their dual impact on both the mother’s mental health and the food security of the household.


Photo by Annie Spratt, Unsplash

References

  • Effects of maternal depression on family food insecurity by Noonan, K., Corman, H., & Reichman, N. E. (https://doi.org/10.1016/j.ehb.2016.04.004)
  • Factors associated with household food insecurity and depression in pregnant South African women from a low socio-economic setting: a cross-sectional study by Abrahams, Z., Lund, C., Field, S., & Honikman, S. (https://doi.org/10.1007/s00127-018-1497-y)
  • Food insecurity among adults residing in disadvantaged urban areas: potential health and dietary consequences by Ramsey, R., Giskes, K., Turrell, G., & Gallegos, D. (https://doi.org/10.1017/S1368980011001996)
  • Food Insecurity and the Risks of Depression and Anxiety in Mothers and Behavior Problems in their Preschool-Aged Children by Whitaker, R. C., Phillips, S. M., Orzol, S.M. (https://doi.org/1542/peds.2006-0239)
  • Food Insecurity/Food Insufficiency: An Empirical Examination of Alternative Measures of Food Problems in Impoverished U.S. Households by Scott, R. I.
  • Food Insecurity and Mental Health among Females in High-Income Countries by Maynard, M., Andrade, L., Packull-McCormick, S., Perlman, C., Leos-Toro, C., & Kirkpatrick, S. (https://doi.org/10.3390/ijerph15071424)

The Relationships Between Domestic Violence and Perinatal Depression and Anxiety – A Global Perspective

According to the World Health Organisation (WHO), depression is the leading cause of disability worldwide and is a major contributor to the overall global burden of disease. Since women are twice as likely to experience depression in their lifetime than men, it is worthwhile to explore the many risk factors that make them more susceptible.

Although depression and anxiety can have devastating effects for any individual – women have an increased chance of being affected by these common mental disorders during the perinatal period, which can have long term consequences for both mother and child.

Domestic violence (DV) and intimate partner violence (IPV) are strongly linked to depression and anxiety in the perinatal period.

Zooming in on Domestic Violence as a risk factor

Domestic violence (DV) is defined as any physical, sexual, psychological or economic abuse that takes place between people who are sharing or have recently shared a home. Intimate partner violence (IPV) relates to violence committed by a current, ex- or would-be intimate relationship that causes physical, psychological or sexual harm to either partner.

The WHO has acknowledged that all forms of interpersonal violence leads to negative health outcomes and released a global plan of action to address interpersonal violence, particularly against women, girls and children. (More in this WHO report 2016)

In Africa, there is more violence against women than on any other continent. Compared to America, twice as many women In South Africa are killed by their partners.

Violence against women during pregnancy can have negative effects for both the mother and the child. Studies have shown that negative physical effects for mother and child can include fetal death by placental rupture, premature labour, low birth weight and haemorrhage after birth.

The negative psychological effects can include lowered self-esteem, depression, anxiety, substance or alcohol misuse. These effects, in turn, render women more vulnerable to experiencing domestic violence. Furthermore, abused women are more likely to delay getting pregnancy care and to attend fewer antenatal visits.

Research on IPV from four countries

Main findings from four countries show that there is a relationship between domestic and intimate partner violence.

A recent study from Australia found that out of the 4% of pregnant women who reported a history of IPV during a routine psychosocial assessment, more than 50% were immigrants. The highest number of women reporting abuse were born in Sudan and New Zealand, while women from China and India were least likely to report IPV. It is important to note that under-reporting is very likely in many communities and this may be due to a variety of reasons such as women’s experiences of shame, stigma and lack of appropriate responses or support from others.

Those women reporting IPV were more likely to report additional psychosocial concerns including depression, thoughts of self-harm and childhood abuse.

Another study conducted in Japan showed the association between verbal and physical abuse during pregnancy and linked it to postpartum depression. The study not only offers some insights into the significant influence of both verbal and physical abuse during pregnancy on postpartum depression, but also calls for regular screening for antenatal IPV by public health nurses who could identify those women who need further support, such as referral to centres for confidential advice and support.

Similar findings were reported from Malaysia, where the exposure to IPV was significantly associated with postnatal depression. The researchers of this study are also calling for training to healthcare professional to detect and manage both problems.

A recent South African study, conducted by the Perinatal Mental Health Project, showed 15% of nearly 400 pregnant women experienced IPV. We found a substantial proportion of women were additionally experiencing violence in the home at the hands of family members other than their partners, such as brothers, in-laws and grandparents. We found that abused pregnant women are more likely to be under 30 years of age, experience a range of mental health disorders, food insecurity and are more likely to be unemployed. They are more likely to have experienced abuse in the past and be unhappy with being pregnant.

‘The atmosphere was tense in the house’ a South African mother’s story.

Next steps

  1. Research

Further research is needed to establish the best way to identify women at risk of domestic violence or intimate partner violence. A recent systematic review showed that there is promising evidence to indicate that mental health interventions for mothers may reduce their experiences of IPV. However, further research is required to determine the mechanisms and intensity of these interventions.

  1. Training and supervision

Trauma-informed care, empathy training, referral-making skills and safety planning should be embedded as an integral part of the training and supervision systems for all frontline workers who engage with mothers, across different sectors.

Clinical and policy guidelines provided by the World Health Organisation are available here.

  1. Systems strengthening

Political will, with the attendant resource allocation, is required to develop the structures able to protect and support survivors. These structures in health (physical and mental), justice, and the non-governmental sectors should operate in a co-ordinated and mutually enhancing way.

The World Health Organisation has produced an excellent manual for health managers for systems strengthening to respond to women subjected to IPV and sexual violence. This includes building awareness, advocating, analysing and planning as well as addressing leadership and governance factors.

Looking back and moving forward for #globalPMH

Our first newsletter of the year reflects on 2018 and takes a sneak peek into projects and research still to come.

 

What a year it’s been!
Find out what we’ve achieved and view the highlights of our activities in 2018 in our Annual Report

Bringing mental health of mothers into the spotlight in Africa

In most societies, mothers are the primary providers of care to young children. This is a demanding task and the mental health of a mother is not only essential to her well-being, but that of her child’s physical health, nutrition and psychological well-being. However, most child development programmes do not adequately address maternal mental health.

Recent research has shown that about 20% of mothers in developing countries experience some form of mental health problems during or after childbirth. The United Nation’s Secretary-General António Guterres has recently acknowledged that the issue of mental health remains a largely neglected issue and announced the UN’s commitment to “working with partners to promote full mental health and well-being for all”.

Moreover, professionals in the field are pointing out that the mental health of mothers is critical to the success of the UN Sustainable Development Goals on health, nutrition and gender equality (SDG 3, 2 and 5).

In South Africa, the rate of pregnant and postnatal mothers suffering from common mental disorders (depression and/or anxiety) can reach up to one in three. Many of them are poor, come from disadvantaged communities and face many obstacles in accessing services and care.

Across Africa, the majority of women experiencing challenges to their mental health during the perinatal period (pregnancy and up to one year after the birth) are also exposed to gender-based violence, economic and gender inequalities, physical illnesses (including HIV), complications of childbirth and the stresses of childcare. Suicide has been identified as one of the leading causes of maternal death worldwide.

Unfortunately, health care systems in most African countries are not equipped to deal with the complex health and social challenges faced by most mothers. With competing physical health priorities and constrained resources, mental health care remains seriously neglected.

To challenge the status-quo and to improve the mental health of mothers in Africa, a group of individuals and organisations are working together in the newly established African Alliance for Maternal Mental Health (AAMMH).

AAMMH believes that a multi-sectoral approach is needed to tackle the causes of poor maternal mental health in Africa. The alliance calls for the integration of existing evidence-based interventions for the detection, prevention and treatment of maternal mental health problems into reproductive and child health programmes, supported by mental health services with specialist expertise.

This call for action is very close to the PMHP’s mission to develop and advocate for accessible maternal mental health care that can be delivered effectively in low-resource settings. We have thus become involved with the Global Alliance for Maternal Mental Health (GAMMH) over the past year since its formation and are now a proud founding partner of its first regional off-shoot, the AAMMH.

Together with colleagues in Malawi, we have been preparing for the upcoming launch on the 19 June in Lilongwe, Malawi. Prior to the launch, we will conduct a training workshop with health care providers and managers in maternal, mental and child health. On the launch day itself, we will be delivering a keynote address sharing the experience of the PMHP and will also be conducting a workshop towards establishing strategies for working partnerships across sectors for maternal mental health.

We hope our experience and work in South Africa, and in other low and middle-income countries, will contribute to the development and growth of this pan-African advocacy initiative. At the same time, we look forward to collaborating and learning from advocates, practitioners, trainers and researchers across Africa to strengthen the work we do in South Africa.

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The African Alliance for Maternal Mental Health (AAMMH) is part of the Global Alliance of Maternal Mental Health and works in close collaboration with the Marcé Society African Regional Group.

AAMMH will be officially launched in Lilongwe, Malawi on 19 June 2018. You can follow the event by using the hashtag #AAMMH #GAMMH

Read more about aims and objectives of the AAMMH here.

Addressing the Maternal Mental Health Diagnosis Gap through screening tools

Source: Maternal Health Task Force blog

Diagnosis gap in Low- and Middle-Income Countries (LMICs)

Despite contributing significantly to maternal deaths and unproductive life years, common perinatal mental disorders (CPMD) often go undetected among women in low-resource regions. This can mean that up to 80% of women remain untreated in such settings. Resource-constrained primary care centers, high patient volumes, lack of recognition by health workers as well as increased task shifting to semi-skilled health workers contribute to this treatment gap. In order to encourage timely identification of CPMD among mothers followed by referrals, antenatal care provision centers are a promising platform in LMICs due to the high level of touchpoints between expectant women and health systems. In South Africa, for example, a mother’s contact rate with any antenatal care facilities is quite high at approximately 91%. […]

Empathic engagement training

Lead author Thandi van Heyningen shares insight into progress and next steps for improving maternal mental health in low-resource settings:

“Where health system resources are scarce, one way of improving detection and improving access to treatment, is to integrate these services into existing, routine, primary health care services using a stepped care approach. Improving detection through routine antenatal screening may provide a vital first step, however there is a need to generate further evidence on the feasibility and acceptability of existing screening tools for use in such settings, and by non-specialist health care workers.”

Read the full paper “Comparison of mental health screening tools for detecting antenatal depression and anxiety disorders in South African women” in the MHTF-PLOS collection on NCDs and maternal health

Suicidal thoughts during pregnancy

Perinatal depression and anxiety are serious mental health problems and are among the leading causes of maternal morbidity and mortality worldwide!

Pregnant women are at higher risk for suicidal ideation and behaviours compared to the general population.

Suicide has been identified as one of the major contributors to the global mortality burden and there is a growing concern over the increase in suicidal ideation and behaviour among pregnant women.

Studies in low- and middle-income countries put the rate of maternal death due to suicide at somewhere between 0.65% and 3.55%. In such cases, risk factors include poverty, lack of support, lack of trust in health systems and coexisting mental illnesses.

Suicidal thoughts experienced during pregnancy can continue beyond the initial postpartum period, affecting the well-being of both mother and child.

More about pregnancy and suicidal ideation in our infographic

Breaking the negative cycle of mental ill-health and poverty during the perinatal period

The negative cycle of mental ill-health and poverty is particularly relevant for women and their infants during the perinatal period. During this time, major life transitions render women more vulnerable to mental illness from social, economic and gender-based perspectives.

Those with the most need for mental health support, have the least access. Overburdened maternal and mental health services have not been able to address adequately this significant unmet need. There have been limited attempts at a programmatic level, to integrate mental health care within maternal care services.

The perinatal period, where women are accessing health services for their obstetric care, presents a unique opportunity to intervene in the event of mental distress. Preventive work involving screening and counselling may have far-reaching impact for women, their offspring and future generations.

Mental health care is a notoriously neglected area – even more so in “healthy” pregnant and postnatal women. The focus on the physical to the detriment of the emotional is particularly felt now against the backdrop of HIV and AIDS. The public health service has been unable to address the mental health needs of women from poorer communities – neither within maternity services nor within mental health services. This is despite a wide body of evidence showing that distress in the mother may have long-lasting physical, cognitive and emotional effects on her children.

Integrating mental health into maternal care in South Africa

The PMHP aims to integrate mental health service routinely, within the primary maternal care environment.
Based at selected government MoU facilities in Cape Town, we offer counselling and support services focused on the emotional wellbeing of pregnant women with a strong focus on postnatal and clinical depression.

Breaking the link between gender-based and intimate partner violence and HIV

Intimate partner violence (IPV) during or before pregnancy is associated with many adverse health outcomes.

Pregnancy-related complications or poor infant health outcomes can arise from direct trauma as well as physiological effects of stress, both of which impact maternal health and fetal growth and development.

Antenatal care can be a key entry point within the health system for many women, particularly in low-resource settings. Interventions to identify violence during pregnancy and offer women support and counselling may reduce the occurrence of violence and mitigate its consequences.

This research will provide much-needed evidence on whether a short counselling intervention delivered by nurses is efficacious and feasible in low-resource settings that have a high prevalence of IPV and HIV.

Source: BMC Health Services ResearchBMC series

Follow the project: BioMed Central

Why we should care about maternal mental health

Empathic engagement with mothers

Image: Graeme Arendse

When I examined Johanna*, I noticed that Johanna was very quiet during the examination. Although everything was fine with the pregnancy, I knew that something was wrong. Johanna had filled in a mental health screening questionnaire, which is routinely offered in our clinic. She had a high score. When I approached Johanna to offer a referral to the PMHP counsellor, she started crying. When I asked what was wrong, Johanna said I can’t talk about it. She did, however, want to see a counsellor.

This is only one of many stories we hear from our nurses and midwifes at at one of our service sites. So why is it important that we train health and social workers and advocate for routine mental health screening in all maternity units in the country?

Read about Johanna’s way out of an abusive relationship and how the counselling empowered her to seek help here

What is perinatal mental health?

Some people may be confused about some of the words used in relation to maternal mental health, like ‘intrapartum’, post-partum’, ‘ante-natal’, ‘post-natal’. The time during pregnancy, may be called the ‘antenatal’ or ‘prenatal’ period. ‘Postnatal’ refers to the time after birth. In the mental health field, postnatal may refer to 6 months or 12 months after the birth. Intrapartum usually refers to the labour and delivery time. ‘Perinatal’ refers to the time from the beginning of pregnancy to the end of the first year after the birth.

It is important not to confuse the ‘baby blues’ with postnatal depression. The ‘baby blues’ occurs in about 60-70% of mothers. Feelings of being overwhelmed and tearfulness occur on the third or fourth day after the birth and these resolve usually within a week. Depression or anxiety are more serious conditions and usually require some form of treatment. Depression or anxiety may occur during pregnancy, after pregnancy or in both time periods. The symptoms of these conditions may be confused with the usual physical symptoms of pregnancy such as sleep and appetite changes, aches and pains, tiredness or changing emotions. However, depression and anxiety affects a person’s mood, thoughts and how they function in most areas of their lives.

‘Psychosis’ is when a person becomes out of touch with reality. Postpartum psychosis is actually rare. It occurs in about 1 in every 1000 women (0.1%) who have a baby. This illness, if rapidly and effectively managed, usually resolves completely so that mothers may return to being well and fully functional.

Find more definitions on perinatal mood disorder here

Why should we care about it?

Perinatal depression and anxiety are significant mental and public health problems with well-documented consequences for mothers, children, and families. In developed countries, suicide is a leading cause of maternal death.

Because of the stigma of mental illness and a lack of understanding, many women who suffer from depression and anxiety, and their families, are not aware that these conditions require treatment (like any other health condition) and that they can be managed (often with relatively simple methods) so that they can recover fully.

Mental health care usually starts with some form of ‘talking therapy’. This can provide the necessary support to empower a women to identify resources and personal capabilities. A therapeutic relationship can enhance a woman’s resilience to difficult life circumstances and support her to nurture her children optimally. Caring for mothers is thus a positive intervention for long-term social development. Many women may also safely benefit from antidepressant medication which effectively treat both depression and anxiety.

How many are affected?

According to the World Health Organisation, worldwide about 10% of pregnant women and 13% of women who have just given birth, experience a mental disorder, mainly depression. In developing countries this is even higher, i.e. 16% during pregnancy and 20% after child birth.

In South Africa, studies show that at least one in every five women suffering during or after pregnancy.

1 in 5 women suffering from depression

Why is mental illness during and after pregnancy so common in South Africa?

Pregnancy and the postnatal period is a psychologically distressing time for many women, particularly for those living in poverty, or with violence, abuse, HIV/AIDS or an unintended pregnancy. Many women in South Africa live in these circumstances.

Several studies on prevalence of common perinatal mental disorders in low and middle income countries are collated on our website.

Who is at risk?

Infographic: Anisha Gururaj and Ashley Pople

Perinatal mental health is connected to a wide range of issues faced by women and although many of the risk factors are common for all women, they can vary from country to country. See the infographic below for comparative risk factors between India and South Africa.

Women in South Africa are particularly at risk when faced by:

  • Domestic violence – violence contributes to poor mental health, and poor mental health makes it more difficult for women to negotiate relationships where there is conflict
  • HIV/AIDS– HIV puts people at greater risk of mental health difficulties, while poor mental health makes it less likely that those who are HIV positive to adhere to treatment
  • Refugee issues– women who are refugees are more likely to suffer mental health difficulties due to their past experiences and to a current lack of support
  • Substance abuse – poor mental health makes women more likely to use substances such as alcohol in an attempt to feel better, but in turn, these substances and the circumstances around using them, lead to worse mental health
  • Teen pregnancy – teenagers with poor mental health are more likely to engage in risky behavior and become pregnant, while pregnancy brings increased social and emotional pressures which then affect mental health

What can we do about it?

Education is key and it is important that mothers and families are sensitized. Informing mothers about perinatal mental health will go a long way in helping them manage depression, anxiety and related illnesses. This education must include information about how to get help and support.

The support may be emotional, practical or financial. Partners should pay attention to the needs of the mothers as well as their own mental health. Seeking help when it is necessary for either or both parents, is a useful way to cope with difficult circumstances. This may be from family, community, health or social workers or faith-based organisations.

Find out where you can receive help in South Africa here

*The PMHP is committed to client confidentiality in keeping with the ethical requirements of professional mental health practice. The client stories reflect common scenarios or sets of circumstances faced by many of our clients. Pseudonyms are used and details are changed. The stories are not based on any one particular woman’s experience, unless an individual explicitly chooses to share her story with or without her name attached.  

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